Every finding on record at Exceptional Care for Children

Based on observation, interview, and record review, it was determined that for four (R13, R21, R24, and R27) out of twenty-two sampled residents, the facility failed to ensure enhanced barrier precautions (EBP) were followed. Findings include:According to the CDC (Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs, Updated July 12, 2022),Nursing home residents with wounds or indwelling medical devices, such as catheters, tracheostomies (breathing tubes), or feeding tubes, are more likely to get and carry these germs.Enhanced Barrier Precautions (EBP) are designed to reduce the spread of these germs.EBP includes the use of a gown and gloves when providing high contact care to these residents. High contact care includes dressing, bathing, transferring, providing hygiene, changing linens, device care, and wound care.Review of the facility's policy and procedure for Enhanced Barrier Precautions, last reviewed 1/26, revealed that . Enhanced Barrier Precautions are implemented for all Exceptional Care for Children residents due to existing indicators; currently all residents have at least one indicator. Staff are to wear gowns and gloves for all high contact resident care activities, which includes device care and use.1. Review of R13's record revealed:5/22/24 - R13 was care planned for EBP related to G tube (feeding tube) and tracheostomy (breathing tube). Interventions include Gowns/gloves will be worn by staff during close contact interventions. 05/12/26 1:08 PM - P1 (Medical Doctor), and E10 (RN) were observed in the community playroom evaluating R13. P1 and E10 were not wearing gowns while assessing R13's tracheostomy stoma, ears, and mouth. 5/12/26 2:21 PM - A progress note by E10 documented, .Trach (sic) stoma, mouth and ears assessed with drainage noted from L ear.2. Review of R24's record revealed: 5/22/24 - R24 was care planned for EBP related to G/J tube (feeding tube) and tracheostomy. Interventions include Gowns/gloves will be worn by staff during close contact interventions. 5/12/26 1:08 PM - P1 and E10 were observed in the community playroom evaluating R24. P1 and E10 were not wearing gowns while assessing R24's tracheostomy stoma, ears, and mouth. 5/12/26 2:34 PM - A progress note by E10 documented, .Trach stoma, mouth and ears assessed with no concerns.3. Review of R21's record revealed:5/22/24 - R21 was care planned for EBP related to G/J tube and tracheostomy. Interventions include Gowns/gloves will be worn by staff during close contact interventions. 5/12/26 1:15 PM - P2 (PA) was observed in the community playroom evaluating R21. P2 was not wearing gowns while assessing R21's tracheostomy stoma, ears, and mouth. 4. Review of R27's record revealed:5/22/24 - R27 was care planned for EBP related to G/J tube and tracheostomy. Interventions include Gowns/gloves will be worn by staff during close contact interventions. 5/14/26 approximately 2:45 pm - E9 (RN) was observed in the community playroom administering medications to R27 through the G/J-tube. E9 was not wearing a gown. 5/14/26 approximately 3:00 PM - Interview with E9 revealed that staff do not follow EBP when administering medications through feeding tubes while residents are in the common areas. 5/18/26 approximately 1:00 PM - An interview with E10 revealed that facility staff, including providers, do not follow EBP when rounding or caring for residents in the playroom. E10 stated that EBP is not something we have to do when the residents are cared for in the playroom.5/18/26 approximately 2:00 PM - During an interview, findings were reviewed and confirmed with E6 (RN, Clinical Support Services Manager).5/19/26 3:45 PM - Findings were reviewed with E1 and E3 during the exit conference.

Based on interview and record review, it was determined that for one (R41) out of one resident reviewed for resident rights, the facility failed to have evidence of notification to law enforcement after a controlled medication was not returned to the facility. Findings include:Review of R41's clinical record revealed:7/30/2024 - R41 was admitted to the facility with diagnoses including spastic quadriplegic cerebral palsy.1/23/26 - An order entered in R41's clinical record documented, diazepam - Schedule IV [controlled substance] tablet.Special instructions: Give every 6 hours as needed for increased spasticity, prior to transport.4/3/26 1:53 PM - A Nursing Progress Note documented, [FM1] arrived to pick up [R41] around 1230 [12:30 PM] for LOA [leave of absence].[R41] left the facility.with all necessary equipment, medications, and tube feeding.4/3/26 - A facility document entitled, Resident Leave of Absence Request and Agreement signed by FM1 documented, .Any unused medication must be returned to the facility upon the resident's return.Medication Name: diazepam Dose: 3 mg [milligrams] Quantity Dispensed: 2 doses.4/5/26 12:43 AM - A Nursing Progress Note entered by E11(RN) documented, [R41] returned to facility from LOA with [FM1].All equipment returned.[FM1] refused to return the doses [diazepam] and put the two unused doses of diazepam back into her personal bag.Doses [diazepam] marked under missing supplies on LOA paperwork, on-call administrative team and DON notified via email.4/5/26 3:00 AM - A facility document entitled, Patient Incident Report was completed and signed by E11 documented, .[R41] returned from LOA at 2355 [11:55 PM] instead of 2100 [9:00 PM].[FM1] asked this nurse [E11] what is done with unused diazepam doses. [E11] stated that we have to properly dispose of them.[FM1] then put the diazepam (2 unused doses) back into her personal bag and stated, 'Well then I'm taking these back home to save for next time if you're just going to throw them out.'.admin [Administrator] on-call notified via email.4/15/26 1:29 PM - A Nursing Progress Note entered by E12 (ADON, LPN) documented, On 4/6 [4/6/26] it was reported that [R41] returned from LOA with [FM1] and that [R41]'s 2 doses of prn (sic) [as needed] valium [diazepam] were unused.This nurse [E12] and DON have attempted to call [FM1] by phone since 4/7 [4/7/26]. On this day, this nurse texted [FM1] at 1049 [10:49 AM] requesting she call this nurse.4/20/26 1:11 PM - A Nursing Progress Note entered by E12 documented, This nurse [E12] spoke with [FM1] regarding the 2 doses of prn (sic) [as needed] valium [diazepam] that was kept by guardian after last LOA. [FM1] informed that she cannot keep any unused narcotics that [facility] must dispose of them properly and keep proper records.5/4/26 10:25 AM - A Nursing Progress Note entered in R41's clinical record documented, [FM1] returned narcotics from [R41]'s recent LOA. Medication was wasted by two nurses per policy.5/19/26 10:00 AM - During an interview, E1 (NHA) stated, I don't have any knowledge of any police reports or of law enforcement being contacted. I was on leave when this incident occurred. [E2, NHA] was the on-call Administrator at the time.5/19/26 10:15 AM - During an interview, the surveyor asked E3 (DON) if law enforcement was notified when FM1 refused to return the diazepam medication. E3 stated, The police were not notified. We updated the LOA policy for drug diversion after this incident to notify law enforcement. The surveyor asked E3 when law enforcement would be notified if a guardian does not return a controlled substance as agreed to the facility upon return from LOA, because it was not stated in the policy. E3 stated, Law enforcement would be contacted because we don't want our nurses to get into an altercation or put themselves in danger.5/19/26 10:30 AM - During an interview, E12 stated, It was hard to get in contact with [FM1] to return the medication. The surveyor asked E12 when law enforcement would be notified if a parent or guardian does not return medication to the facility after LOA. E12 stated, I don't know when the police would be contacted.5/19/26 1:50 PM - During a telephone interview, E11 stated, .I was taken aback when [FM1] would not return the diazepam. The surveyor asked who you informed that FM1 refused to return the diazepam doses? E11 stated, I emailed the Nurse Administrator On-Call [E7], the Administrator On-Call [E2], and the DON [E3]. The surveyor asked E11 if she was aware of the updated LOA policy on drug diversion. E11 stated, I believe we report it to the Administrator and the Education Team. The surveyor asked E11 if law enforcement would be contacted if medication is not returned to the facility when a resident comes back to the facility from LOA. E11 stated, The LOA policy was changed for preventive education. I don't know if law enforcement was a route going to be taken.5/19/26 2:00 PM - Findings were reviewed with E1.5/19/26 3:45 PM - Findings were reviewed with E1 and E3 during the exit conference.

Based on record review and interview, it was determined that for three (R1, R2 and R3) out of three residents reviewed for hospitalization , the facility failed to ensure that the physician conducted the required visits. Findings include: 1. Review of R1's clinical record revealed: 12/28/24 - R1 was admitted to the facility to the facility. 12/28/24 - R1 was examined by a physician and a Health Appraisal Visit documented the encounter in the electronic medical record (EMR). 4/10/24 - R1 was examined by a physician and a Health Appraisal Visit documented the encounter in the EMR. R1 went 104 days between physician visits. During the first 90 days of an admission to a skilled nursing facility, by regulation a patient must be examined every 30 days. 2. Review of R2's clinical record revealed: 5/1/18 - Admission to the facility. 7/25/23 - R2 was examined by the physician and a Health Appraisal Visit documented the encounter in the EMR. 11/14/23 - R2 was examined by the physician and a Health Appraisal Visit documented the encounter in the EMR. R2 went 112 days between physician visits instead of the 60 days as required. 3/4/24 - R2 was examined by a physician and a Health Appraisal Visit documented the encounter in the EMR. R2 went 112 days between physician visits instead of the 60 days as required. 3. Review of R3's clinical record revealed: 7/18/23 - R3 was admitted to the facility. 10/31/23 - R3 was examined by a physician and a Health Appraisal Visit documented the encounter in the EMR. R3 went 105 days between physician visits. During the first 90 days of an admission to a skilled nursing facility, by regulation a patient must be examined every 30 days. 2/13/24 - R3 was examined by a physician and a Health Appraisal Visit documented the encounter in the EMR. 6/4/24 - R3 was examined by a physician and a Health Appraisal Visit documented the encounter in the EMR. R2 went 111 days between physician visits instead of the 60 days as required. 4/17/24 approximately 1:00 PM - During an interview with E3 (Quality Assurance/Infection Control Nurse) it was revealed that the physician visits occur with the quarterly assessments and a physicians' group round on residents once a week. When asked if the facility had evidence that the physicians' group see and examine each resident every every 60 days, E3 stated that all residents were seen quarterly but the physicians group rounds on residents that are sick and or require a visit by the physicians group. 6/17/24 at 2:20 PM - During an exit conference findings were reviewed with E1 (NHA) and E2 (ADON).

Based on interview and review of the clinical record and other documentation as indicated, it was determined that for one (R3) out of one resident reviewed for abuse, the facility failed to ensure that R3, a non-verbal, medically challenged dependent teenager, was free from physical and verbal abuse from a staff person on 9/9/23, which caused R3 to cry. Based on observations of staff interactions with R3 during the current survey, staff interviews, record review since the 9/9/23 incident and consideration of the reasonable person concept revealed that R3 did not have a psychosocial outcome. Review and verification of the facility's immediate actions and no further incidents, the facility was in substantial compliance as of 9/26/23. The 9/9/23 incident was past non-compliance. Findings include: R3's clinical record revealed: 6/14/17 - R3 was admitted to the facility with diagnoses that included, but were not limited to, megalencephaly syndrome (chromosomal abnormality), chronic respiratory failure and tracheostomy. 12/6/18 - R3 was care planned for communication deficit related to cognitive deficit and trach/vent dependent. Interventions included, but were not limited to: - patient is unable to communicate verbally. Monitor facial expressions and vital sign changes; - speak slowly and clearly and repeat PRN (as needed). Communicate at eye level; and - maintain eye contact when interacting with resident. R3 was also care planned for significant and global developmental delays with severe intellectual disability. 12/17/20 - R3 was care planned for behavioral symptoms, including hitting staff and throwing equipment and disconnecting self-off vent/pulse ox and tube feeds. Interventions included, but not limited to: - avoid over-stimulation (e.g. noise, crowding, other aggressive residents); - maintain a calm environment and approach to the resident; - maintain a calm, slow, understandable approach with the resident; - patient cries to make needs known .; - redirect from inappropriate behavior. Provide re-orientation and cues PRN (as needed). Provide verbal reminders related to behaviors .; - when resident begins to become socially inappropriate/disruptive, provide comfort measures for basic needs (e.g. pain, hunger, toileting .). 8/11/23 - The quarterly MDS assessment documented that R3 had minimal difficulty hearing; was rarely/never understood; sometimes understands - responds adequately to simple, direct communication only; had adequate vision; and was severely impaired for daily decision making. 9/9/23 - The facility's incident report documented that approximately 2:30 PM while the CNA (E9) was in the resident's bathroom, she reported hurting (sic) a slap noise while [E10, RT] was in the room with the patient [R3] . The CNA exited the bathroom, and noted the child was crying. The CNA asked the [E10] if everything was ok, to which the [E10] replied the patient tried hitting her. [E10] has been placed on Administrative Leave, pending investigation. 9/9/23 (untimed) - During an interview with E1 (NHA) and E2 (DON), E10's verbal statement was documented by E1 (NHA) as follows: [E1]: [E10, RT] Can you share what happened with you and [R3] today? [E10]: While I was in her room this afternoon [R3] hit me. [E1]: Where did she hit you? [E10]: On my leg. [E1]: Did you touch [R3] at all after she hit you? [E10]: I swatted her away from me. [E1]: Can you please demonstrate? [E10]: Demonstrated on [E1's] arm a pushing away motion to the lower left arm. [E1]: Did you say anything to her? [E10]: I told her to stop hitting. [E1]: Is there anything else you would like to share? [E10]: No. At the conclusion of the interview, [E10] was asked to prepare a written statement and to forward that statement to the DON (E2) and Executive Director (E1). 9/9/23 at 5:42 PM - A nurse's note documented, Spoke with patients [F1, family member] at 1730 (5:30 PM). Informed [F1] of patient's interactions of the day. Patient is currently at her baseline, happy and playing quietly. 9/9/23 at 5:53 PM - A nurse's note documented, This nurse performed a skin check around 1530 (3:30 PM) and 1730 (5:30 PM) per administration. No bruises, red marks or open areas noted. Patient is currently in room watching tv, smiling and neuro status per baseline . MD (Medical Doctor) on call made aware. 9/9/23 at 7:05 PM - An emailed statement from E9 (CNA) to E1 (NHA) documented, Today around 2-3 pm I walked into [R3's] bathroom to document on her clipboard as [E10, RT] did her treatment. I heard commotion as she continued to talk to her in an unprofessional manner. I then intervened and asked her if everything was okay, when she then stated that [R3] is bad and is always swatting at somebody. 9/10/23 at 11:21 AM - A nurse's note documented, Skin assessment performed. Skin clean, dry and intact. No bruises or open areas noted . 9/11/23 - The facility submitted a five-day follow-up to the State Agency: On 09/09/23 it was reported by [E9, CNA] that at approximately 14:25 (2:25 PM) she heard commotion in [R3's] room, while she was in that patients bathroom. [E9] further stated that she could hear [E10, RT] speaking in a (sic) unprofessional manner towards the patient. [E9] left the bathroom to check on the patient and [E10] in the room. [E9] asked [E10] if everything was ok, to which she stated [E10] told her that [R3] had swatted at her. [E9] reported this incident to the charge nurse and [E10] was placed on administrative leave pending investigation. During an interview conducted with [E10] by the [E1, NHA] and [E2, DON] she admitted to swatting [R3] after she had struck [E10], and stated that she told [R3] to Stop Hitting. A review of the video camera footage was conducted by the NHA and DON on 09/09/2023 . shows the child sitting on the floor, which [E10] is straightening up items behind the child in room [XXX]. At approximately 14:23 (2:23 PM) something occurs to which [R3] makes a motion towards [E10]. [E10] pushes her away, then makes a slapping motion toward the child's left lower arm telling her to stop hitting. At which point [E9] is observed walking out of the bathroom into the room to check on the situation. At this point [E10] begins explaining to [E9] that [R3] had hit her. Actions taken: - [E10, RT] was placed on Administrative Leave on 09/09/2023; - Incident was initially reported to DHS (Department of Health Services/State Agency) on 09/09/2023; - Resident was assessed for injury on 09/09/2023 and [F1, family member]/physician were notified. No bruising was noted after the incident on 09/09 or on 09/10; - [Name of] Police were contacted on 09/11/2023 Report #[YY-YY-YYYYY]; - [S1's name], Ombudsman notified on 09/11/2023. Conclusion: In this writer's opinion, Resident Abuse occurred. The first motion by [E10, RT] was not abusive and looked reactionary and as move to protect herself, the second motion where [E10] swatted/slapped [R3] on the left arm was Abusive in my opinion. It is recommended that the employee be terminated, and that this incident be reported to her professional licensing board. 9/11/23 at 3:15 PM - E10's (RT) written statement emailed to E1 (NHA) was as follows: . my account of the alleged incident involving Resident [initials of R3] on 9/9/23 . On the day in question, I wheeled [initials of R3] in her gait trainer to her room for her respiratory treatment. After situating herself nicely on the mat in her room, she began to hit me multiple times as she often does out of anger for being led from the living room. Because of this ongoing negative behavior, I have had to become a little creative in coming up with ways to distract her to redirect her physical behavior. I have danced, [NAME] to her, given her hand or foot massages, and played the . or shoe toss back and forth. On this day however her hitting was exceptionally worse than usual. I found myself having to block shots with my arms and even caught her arm a couple of times mid swing placing it on her lap while sternly saying that we do not hit. My correction and not allowing myself to be hit seemed to anger her more, so as I waited for the treatment to finish, I sang to the video and waved my arm back and forth to prevent her from raising her hand and striking me. As I stated, there was light contact. It came from the backswing of a wave and my fingertips barely touched her left arm. It's possible that the combination of all the above with the light touch and stern correction hurt her feelings, which is why when charge asked about anything occurring, I had no idea why she would be crying. This behavior is more the rule than the exception and occurs regularly. Though there was no deliberation, and the vantage point of the reporter did not give a clear view of the event, I am in 100% agreement with the report to preserve the rights of the resident, even at my expense. I trust that the combination of the video and this account will be what is needed to clear myself . 9/12/23 - The facility's QAPI Committee reviewed the 9/9/23 staff to resident abuse incident. 9/26/23 - E1 (NHA) provided evidence that staff were educated on this day about abuse incident and the importance of reporting during the general staff meeting. Review of the facility's surveillance footage provided to the State Agency revealed: - at 14:23:31 (hour:minute:second), R3 turns her head to left, with left hand swatted/hit E10's (RT) left lower leg. R3's right back hand covering mouth. E10 swats at R3's left hand while stepping back and bending down to R3's face and says, Stop it. Don't you hit. E10 appears to grab the left lower arm of R3 with her right gloved hand and pushed R3's left lower arm down to the floormat while pointing with her finger and stating, Put your hand down. Put it down. Put it down. We're not playing that. RT stated, You need some manners girl while standing behind R3 working with the medical equipment. - at 14:23:46, E9 (CNA) asked E10 if everything was okay. E10 said, I'm hollering at her because she hit me. I'm tired of her hitting me. She knows better. She knows exactly what she is doing. That's what I do with my kids yell at them. - at 14:25:00, R3 turns head to left and E10 said, You better stop looking around behind you. You hit me that's it. E10 was bent over behind R3 and continues to organize medical equipment. E10 stated, You better knock it off girl. R3 was stilled turned to the left where E10 was bent over. - at 14:25:17, E10 responds, Turn around I'm not doing anything to you. - at 14:25:36, E10 said, Turn around and watch the show while pointing her finger toward the TV. R3 was watching E10. E10 responds, I'm fixing things turn around. Cry all you want. I don't care. You hit me. You're in trouble. - at 14:25:56, R3 reached out with left hand and E10 pushed it away. Video ended at 14:26:04. *14:00 = 2:00 PM 5/24/24 at 11:02 AM - During an interview, E11 (RN) confirmed that she was the charge nurse on 9/9/23. E11 stated that E9 (CNA) said that she was in the bathroom and she heard the [E10, RT] say R3's name stop. E11 stated that E9 told her that she heard what it sounded like a slap and when E9 looked over at R3 she was crying. E11 stated that when R3 cries the resident exhibits facial redness, no tears. When R3 was angry, the resident will put out her trach, throw things around her and/or she will hit you. When she grabs or hits you the resident is trying to communicate something she wants. E11 stated that R3 has had the grabbing/hitting behavior before this incident. E11 stated that R3 can't communicate and can't understand why she can't have things when she wants it. E11 stated that it is acceptable to tell her to stop hitting. However, E11 stated it was not acceptable at the facility to hit any child or yell at a child. E11 stated that she requested E10 (RT) to leave the patient floor and immediately checked on R3. E11 stated that upon her assessment, R3 was completely as baseline and performed a skin check with no injuries or signs of pain. E11 stated that R3 would exhibit pain by crying with mouth wide open/no noise. E11 stated that R3 appeared happy as she was clapping while watching her favorite movie, Frozen. E11 immediately notified E2 (DON) and remembered that E1 (NHA) and E2 (DON) arrived at the facility super quick to review the surveillance camera footage. E11 also stated that she notified the physician. 5/24/24 at 12:45 PM - During an interview, E12 (RN) confirmed that she was R3's assigned nurse on 9/9/23 during the incident. E12 stated that she went into R3's room to administer medications and the charge nurse (E11) came into the room informing her of the incident and performed a full body skin assessment. E12 stated that on that day R3 was more agitated than usual right from the beginning of the shift. E12 stated that this usually happened on weekends when R3 was not in a structured environment. When asked if R3 was acting any different after the incident, E12 (RN) stated No. I would not have known had I not been told about the incident. 5/24/24 at 12:56 PM - Surveyor left voicemail for E10 (RT) and as of 5/28/24 at 8:38 AM, no return call was received. 5/28/24 at 10:15 AM - During an interview, E1 (NHA) stated that E10 was immediately suspended on 9/9/23 pending the investigation. E10 never returned to the facility and was terminated on 9/13/23 by phone. E1 stated that QAPI Committee reviewed the incident and staff were in-serviced for abuse prevention on 9/26/23. When asked if there have been any abuse incidents since 9/9/23, E1 stated no. When asked how you assure retaliation does not occur when staff report an allegation of abuse, E1 stated that in this case he wrote a letter to E9 stating how she did the right thing for reporting it. E1 stated that he encourages staff to report and educates staff by using a real life example of an allegation of abuse that occurred in the past at another facility. E1 stated that he tells his staff to trust the process. 5/28/24 at 11:27 AM - During an interview, E2 (DON) confirmed that she was notified by E11 (RN/Charge Nurse) and E10 was removed from patient care and suspended then terminated. When asked if any medical interventions were done, E2 stated no medical interventions were required. R3 was back to baseline with no noted changes. E2 stated that R3 had behaviors of swatting/hitting prior to and after the 9/9/23 incident. Verification of the facility's immediate actions taken after the 9/9/23 incident included: - suspended E10 (RT) on 9/9/23 and then terminated on 9/13/23; - assessed R1 after incident and continued to monitor; - notified F1 (R1's representative) and the Physician on 9/9/23; - other residents were assessed by nursing on 9/9/24 and 9/10/24; - conducted a facility investigation and maintained evidence; - conducted a QAPI Committee review on 9/12/23; - reported incident to the State Agency, Ombudsman's Office, local law enforcement and Delaware Professional Regulations Agency; and - in-serviced all staff regarding the facility's abuse policy and reporting on 9/26/23. The facility was in substantial compliance as of 9/26/23. 5/28/24 at 2:00 PM - Findings were reviewed with E1 (NHA), E2 (DON), E4 (Medical Director) and a representative from the Ombudsman's Office.

Based on record review and interview, it was determined that for four (R3, R21, R28, R33) out of eight residents reviewed for resident assessments, the facility failed to accurately report the resident's status. Findings include: According to the CMS (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 Manual, October 2023, page A-20, under A1005 Ethnicity and A1010 Race, the Steps for Assessment: Interview Instructions . 2. If the resident is unable to respond, the assessor may ask a family member, significant other, and/or guardian/legally authorized representative . 4. Respondents should be offered the option of selecting one or more ethnic [and racial] designations . 5. Only use medical record documentation to code A1005, Ethnicity [and A1010 Ethnicity] if the resident is unable to respond and no family member, significant other, and/or guardian/legally authorized representative provides a response for this item . Code X, Resident unable to respond: if the resident is unable to respond. In cases where the resident is unable to respond and the response is determined via family, significant other, or legally authorized representative input or medical record documentation, check all boxes that apply, including X. Resident is unable to respond . 1. R3's clinical record revealed: 4/30/24 - E7 (MD) documented in the Physician Medical Update letter that R3 was nonverbal and had significant and global developmental delays with severe intellectual disability. 5/13/24 - R3's annual MDS (Minimum Data Set) assessment documented in Section A under A1005 Ethnicity, X. Resident unable to respond and under A1010 Race, X. Resident unable to respond. The MDS documentation failed to provide any other information regarding R3's ethnicity or race. 5/24/24 - Review of R3's facesheet demographics revealed that R3's race was white. 2. R21's clinical record revealed: 3/14/24 - E6 (MD) documented in the Physician Medical Update letter that R21 was nonverbal and globally delayed with severe intellectual disability. 4/21/24 - R21's quarterly MDS assessment documented in Section A under A1005 Ethnicity, X. Resident unable to respond and under A1010 Race, X. Resident unable to respond. 5/24/24 - Review of R21's facesheet demographics revealed that R21's race was black or African American. 3. R28's clinical record revealed: 2/29/24 - E5 (MD) documented in the Physician Medical Update letter that R28 was nonverbal and had global developmental delays. 4/13/24 - R28's quarterly MDS assessment documented in Section A under A1005 Ethnicity, X. Resident unable to respond and under A1010 Race, X. Resident unable to respond. 5/23/24 - During an interview, E8 (RN) stated that R28 was of Middle Eastern descent but was not sure what country his family comes from. His (family member) speaks Arabic. 5/24/24 - Review of R28's facesheet demographics revealed that the section on race and ethnicity were not completed. 4. R33's clinical record revealed: 11/8/23 - E6 (MD) documented in the Physician Medical Update letter that R33 was nonverbal . with severe intellectual disability. 4/19/24 - R33's quarterly MDS assessment documented in Section A under A1005 Ethnicity, X. Resident unable to respond and under A1010 Race, X. Resident unable to respond. 5/24/24 - Review of R21's facesheet demographics revealed that R21's race was Hispanic, Latino and/or Spanish origin. 5/28/24 12:04 PM - During an interview, E3 (ADON) stated, The reason that I don't document race or ethnicity is that it is an interview question and most of our residents are not interviewable. The facility failed to ensure that each residents' MDS assessment accurately reflected the residents' status with respect to ethnicity and race. 5. According to the CMS RAI Version 3.0 Manual, October 2023, page N-9, Anticoagulants such as Target Specific Oral Anticoagulants (TSOACs), which may or may not require labarotory monitoring, should be coded in N0415E, Anticoagulants. Do not code flushes to keep an IV access port patent. R33's clinical record revealed: 3/23/24 - E6 (MD) ordered in R33's electronic medical record (EMR), Heparin lock flush (porcine) 10 units/ml (milliliters) 5 ml IV (intravenous) once a day. DX (diagnosis) . management of vascular access device. 4/19/24 - R33's quarterly MDS assessment documented in Section N under N4015 High Risk Drug Classes - Uses & Indications that R33 was ordered E. Anticoagulants . 5/24/24 - Review of R33's active physician orders revealed no evidence of any anticoagulants ordered for R33. The facility failed to accurately code R33's 4/19/24 quarterly MDS assessment with respect to anticoagulant use. 5/28/24 at 2:00 PM - Findings were reviewed with E1 (NHA), E2 (DON), E4 (Medical Director) and a representative from the Ombudsman's Office.

Based on record review and interviews it was determined that the facility failed to revise the care plan to reflect current resident's needs for two (R8 and R9) out of 12 sampled residents. Findings include: 1. R8's clinical record revealed the following physician's orders [REDACTED].>12/20/17 - Left, Comfy hand splint to be worn 3 hours on, then 1 hour off throughout the night. 12/21/17 - Bilateral Benik hand splints to be worn 3 hours on, then 1 hour off throughout the day. Review of R8's comprehensive care plan, effective date 9/17/18, failed to be revised to reflect use of the above mentioned hand splints. 9/17/18 approximately 3:55 PM - In an interview, E3 (RNAC) confirmed that R8's care plan failed to reflect the use of the hand splints. 9/17/18 approximately 5:45 PM - Findings were reviewed with E1 (NHA) and E2 (DON). 2. R9's clinical record revealed the following physician's orders [REDACTED].>10/8/15 - Bilateral hand splints 2 hours on 2 hours off during waking hours. 10/12/15 - Bilateral elbow splints 4 hours on 2 hours off at night. Review of R9's comprehensive care plan, effective date 9/17/18, failed to be revised to reflect use of the above mentioned hand and elbow splints. 9/17/18 approximately 3:55 PM - In an interview, E3 (RNAC) confirmed that R9's care plan failed to reflect the use of the hand splints. 9/17/18 approximately 5:45 PM - Findings were reviewed with E1 (NHA) and E2 (DON).

Based on observations, record review and staff interview it was determined that the facility failed to ensure that a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for two (R5 and R8) out of 12 sampled residents. Findings include: 1. Review of R5's clinical record revealed the following: 5/8/04 - R5 was originally admitted to the facility with [DIAGNOSES REDACTED]. 2/7/17 - A physician's orders [REDACTED]. 7/24/18 - A Physician's Medical Update Letter stated R5 has multiple joint contractures and equipment needs included bilateral Posey hand rolls. The following observations were made of R5: 9/10/18 12:50 PM - R5 was lying in bed and did not have any Posey hand rolls in place. 9/11/18 9:50 AM - R5 was in bed with no Posey hand rolls in place. 9/11/18 4:20 PM - R5 lying in bed with a Posey hand roll in place only in the right hand. 9/13/18 11:15 AM and 1:15 PM - R5 was observed lying in bed with no Posey hand rolls in place. 9/13/18 2:17 PM - R5 observed seated in a wheelchair wearing only a right Posey hand roll. The facility failed to ensure that R5, who had limited range of motion due to contractures, received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. 9/17/18 approximately 5:45 PM - During an interview, findings were reviewed with E1 (NHA) and E2 (DON). 2. Review of R8's clinical record revealed the following: 6/19/12 - R8 was originally admitted to the facility with [DIAGNOSES REDACTED]. 12/21/17 - A physician's orders [REDACTED]. 9/17/18 - R8 was observed at 12:14 PM, 1:12 PM, 1:30 PM, 1:45 PM, and 3:15 PM not wearing bilateral Benik hand splints. 9/17/18 approximately 3:55 PM - During an interview, E3 (RNAC) stated that according to R8's CNA it was overlooked. 9/17/18 approximately 5:45 PM - Findings were reviewed with E1 (NHA) and E2 (DON).

Based on kitchen observations and staff interviews, it was determined that the facility failed to store, prepare, distribute and serve food under sanitary conditions. Three resident children eat food prepared in this kitchen. Findings include: Observation of the kitchen area on 6/15/16 at approximately 1:15 PM with E5 (kitchen supervisor) revealed that there was no measurable sanitizer in the three compartment sink. Using the facilities quaternary ammonia test strips, the reading on the test strip read zero ppm indicating that there was no measurable sanitizer in the three compartment sink. In order for dishes, utensils pots etcetera to be sanitized using quaternary ammonia the concentration must be at leased 200 ppm. After making the observation with E5 the sink was drained and refilled with the quaternary ammonia being automatically dispensed. When filled the sink was again tested with a test strip. The test strip again read zero. The test strip was also tested with the concentrated quaternary ammonia solution from the dispensing bag to make sure the test strips were working. The test strip turned purple indicating the test strips were working. While the sink was filling up it was noted that large quantities of air were getting into the sanitizer dispense tubing. The sink was not receiving the proper amount of sanitizing solution from the automatic pump to properly sanitize items being washed in the three compartment sink. The facility called the kitchen vendor and the automatic pump was replaced the evening of 6/15/2016. The three compartment sink was again tested on [DATE] at 1:08 PM and the test strip measured 200 ppm of quaternary ammonia indicating proper concentration of sanitizing solution. During an interview findings were reviewed with E1 (NHA) and E2 (DON) on 6/21/16 at approximately 2:00 PM.

Based on the medication pass observations, review of clinical records and interviews, it was determined that for 2 (R4 and SSR13) out of 12 sampled residents, the facility failed to provide the care and services necessary to maintain the highest practicable physical well-being in accordance with each individual's plan of care. For R4 and SSR13, the facility failed to discontinue old physician orders [REDACTED]. Findings include: 1. SSR13 was observed during medication passes on 6/17/16 at approximately 12:25 PM and on 6/20/16 at approximately 8:40 AM. Between the two medication passes, SSR13 was administered the following medications via GT: [MEDICATION NAME], [MEDICATION NAME] and Pediatric Multivitamins with Iron. Review of physician's orders [REDACTED]. Review of the June 2016 MAR (from 6/1/16 - 6/20/16) revealed that the medications were to be given via GT and they were signed by nurses as having being administered via GT. Concerns were discussed with E2 (DON) and E3 (RNAC) during an interview on 6/20/16 at approximately 12:00 PM. E3 confirmed findings and stated that SSR13 does not have a JT anymore, medications have been administered via GT since 11/11/15. 2. R4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R4 was hospitalized for [REDACTED]. A physician's orders [REDACTED]. It was unclear why the facility entered this physician's orders [REDACTED]. A physician's medical update letter, dated 5/18/16, stated that R4 received all of his caloric and fluid requirements via the GT. However, after his recent surgery, R4 had a GJ-tube placed to prevent pancreatitis. The plan was to gradually advance him back to receiving all medications and tube feeds via the GT. Review of R4's May 2016 MAR indicated [REDACTED]. A nurse's note, dated 5/16/16 and timed 11:36 PM, stated that R4's GJ-tube was pulled out. The physician was notified and ordered to replace the GJ-tube with a GT. In addition, the physician ordered that medications were to be given via the GT. In an interview on 6/17/16 at 4:10 PM, E3 (RNAC) stated that the computer system does not recognize JT as a selected option, but nursing staff can type specific physician order [REDACTED]. Findings were reviewed on 6/20/16 at 11:55 AM with E2 and E3. The facility failed to discontinue old physician orders [REDACTED].

Based on observation, review of the clinical record, facility policy review, and interview, it was determined that the facility failed to meet professional standards of quality. For one (SSR14) out of 12 residents reviewed, the facility failed to have a physician's order for [MEDICATION NAME] that met professional standards of quality; the order lacked a route for the medication to be administered. Findings include: Review of the facility policy entitled Receiving and Recording Medication/Physician Orders, last revised January 2016, stated, . purpose of this policy is to establish guidelines in the receiving and recording of medication and physician orders . When recording orders for medications, you must specify: 1. Drug name and Strength 2. Route of administration . During the medication pass on 6/20/16 at approximately 8:55 AM, E4 (RN) was observed administering medications, including [MEDICATION NAME] via GT to SSR14. When physician orders were checked, the order for [MEDICATION NAME], dated 5/11/16, stated, [MEDICATION NAME] 750 mg Oral Solution b.i.d. Continuous. The physician order lacked a route of administration for [MEDICATION NAME] and there were multiple opportunities for nursing staff to have clarified the physician order to include the route of administration. Findings were reviewed and confirmed with E2 (DON) during an interview on 6/20/16 at approximately 12:00 PM.

Based on clinical record review and interview, it was determined that for one (R1) out of 12 sampled residents, the facility failed to ensure that a resident with a pressure ulcer received the necessary treatment and services to promote healing. For R1, the facility failed to comprehensively assess R1's pressure ulcer on his right posterior neck when an open area was identified on 5/27/16 until 6/2/16, seven (7) days later. In addition, the facility failed to follow the plan of care when administering a treatment for [REDACTED]. Findings include: The facility's policy entitled Assessment and Re-Assessment of a Resident with a Pressure Ulcer, last revised January 2016, stated, Assessment is the starting point in preparing to treat or manage a resident with a pressure ulcer . Pressure ulcers should be assessed at least weekly . The assigned nurse for each individual resident with a pressure ulcer will assess and evaluate the ulcer each time the dressing is changed . The facility will assign an individual nurse to measure and stage the wound weekly . Measure the wound . Note the location . color of the wound . describe . wound margins and the surrounding skin . describe the exudates color and odor . staging . The facility's policy entitled Pressure Ulcer Treatment Protocol, last revised January 2016, stated, . Preparation: A. Verify that there is a physician's order for this procedure . The facility's wound protocol for altered skin integrity was [MEDICATION NAME] and [MEDICATION NAME] thin to affected areas as needed. R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nurse's note, dated 5/27/16 and timed 5 PM, stated that the facility's wound protocol was initiated for a small open area to R1's right posterior neck. The facility failed to comprehensively assess R1's open area to the right posterior neck. A nurse's note, dated 5/29/16 and timed 5:25 PM, stated that the facility wound protocol was started to the open area on R1's right posterior neck under his [MEDICAL CONDITION] ties and bleeding and tenderness were noted. A nurse's note, dated 5/30/16 and timed 5:32 PM, stated that wound protocol was provided to R1's right posterior neck. A physician's order, dated 5/31/16 and timed 3:53 PM, stated to apply duoderm then [MEDICATION NAME] to the red area on the left side of R1's neck. A nurse's note, dated 5/31/16 and timed 4:01 PM, stated that R1 had an open area with small amount of blood and redness on his right posterior neck. R1's left posterior neck was noted as a thin area with no skin breakdown and the prescribed treatment was duoderm with [MEDICATION NAME] on top. A nurse's note, dated 6/1/16 and timed 12:39 AM, stated that the right side of R1's neck was open. A nurse's note, dated 6/2/16 and timed 4:16 PM, stated that R1's right posterior neck was identified as a Stage 2 pressure ulcer and measured 2.8 cm x 1.3 cm and the facility's wound protocol was applied as the treatment. R1's left posterior neck wound was pink, non-blanchable, intact skin and measured 3 cm x 1.3 cm. Marathon Liquid Skin Protectant covered with [MEDICATION NAME] was applied as the treatment to R1's left posterior neck to keep pressure from his [MEDICAL CONDITION] tie off the wound. It was unclear why the facility failed to comprehensively assess to include measurements, wound description and staging of R1's right posterior neck pressure ulcer when it was first identified on 5/27/16, seven (7) days earlier. It was also unclear why the facility failed to follow the 5/31/16 physician's order for duoderm and [MEDICATION NAME] treatment for [REDACTED]. A nurse's note, dated 6/8/16 and timed 3:30 PM, stated that R1's left posterior neck was assessed and remained a Stage 1 pressure ulcer. Marathon Liquid Skin Protectant was applied as the treatment to R1's left posterior neck. It was unclear why the facility failed to follow the 5/31/16 active physician's order for duoderm and [MEDICATION NAME] treatment for [REDACTED]. In an interview on 6/17/16 at 4:10 PM, E3 (RNAC) confirmed that R1 was not comprehensively assessed when the open area to R1's right posterior neck was identified on 5/27/16. Findings were reviewed with E2 (DON) and E3 on 6/20/16 at approximately 11:55 AM. The facility failed to comprehensively assess R1's pressure ulcer on his right posterior neck when an open area was identified on 5/27/16 until 6/2/16, seven (7) days later. The facility also failed to follow the plan of care when administering a different treatment for [REDACTED].

Based on observation, record review, review of facility policy, and interview, it was determined that the facility failed to maintain clinical records for 2 (R4 and SSR14) out of 12 sampled residents in accordance with accepted professional standards and practices that are complete and/or accurately documented. Findings include: Cross refer to F281 Review of the facility policy entitled Documentation of Medication Administration, last revised January 2016, stated, . Purpose: To provide guidelines for proper documentation when administering medications . Documentation must include: 1. Name and strength of drug 2. Dosage 3. Route . 1. During the medication pass on 6/20/16 at approximately 8:55 AM, E4 (RN) was observed administering medications, including [MEDICATION NAME] via GT to SSR14. Review of the May and June MARs revealed that from 5/12/16 through 6/19/16, SSR14's [MEDICATION NAME] that was given bid lacked a route of administration. Findings were reviewed and confirmed with E2 (DON) during an interview on 6/20/16 at approximately 12:00 PM. Cross refer to F309, example 2 2. A physician's order, dated 5/10/16 and timed 5:55 PM, stated to administer all medications and tube feeds to R4 via JT until further orders. Review of R4's May 2016 MAR indicated [REDACTED] - [MEDICATION NAME] via GT; - [MEDICATION NAME] via GT; - [MEDICATION NAME] powder via GT; - [MEDICATION NAME] via GT; - [MEDICATION NAME] via GT; - [MEDICATION NAME] via GT; - [MEDICATION NAME] via GT; - [MEDICATION NAME] via GT; - [MEDICATION NAME] via GT; and - [MEDICATION NAME] via GT. In an interview on 6/17/16 at 4:10 PM, E3 (RNAC) stated that the computer system does not recognize JT as a selected option, but nursing staff can type specific physician order information under the Scheduled Note. During an interview findings were reviewed on 6/20/16 at 11:55 AM with E2 and E3. The facility failed to ensure R4's clinical record was accurately documented for the above 10 medications over a seven day period.

Based on observations during the medication pass, facility documents and interview, it was determined that the facility failed to maintain an Infection Control Program designed to provide a safe and sanitary environment and to help prevent the development and transmission of disease and infection related to handwashing and medication administration for one (R2) resident out of a total of 10 sampled. Findings include: 1. During the medication pass with E3 (RN) on 5/6/15 from approximately 1:50 PM to 2:05 PM, the following observations were made: a. For R2, E3 popped pills for 2 different medications directly from the bubble pack in which the medications were stored into his hand and then placed the medications into a paper souffle cup. b. For R2, E3 was observed washing his hands and then contaminating his clean hands by using his bare hands to turn off the faucet. Findings were reviewed and confirmed with E3 during an interview on 5/6/15 at approximately 2:06 PM immediately after the medication pass. E3 stated he worked per diem (temporary) in the facility for many years prior to recently changing to full-time status and he did not always have the same resident assignments. Findings were reviewed with E1 (NHA) and E2 (DON) during an interview on 5/7/15 at approximately 12 PM. At approximately 2 PM. E1 and E2 stated the facility has an upcoming skills fair, including the proper transfer of medications from bubble packets to medication cups and for hand washing with return demonstrations by nursing staff. Documents provided by the facility for use in the upcoming skills fair were reviewed. Shared Governance Meeting notes, dated 4/7/15, stated, "... Skills Fair Updates... We have the bubble packets from (name of pharmacy) for proper transfer to med (medication) cup... Hand washing...". The World Health Organization procedure, unable to read date, entitled "How to Handwash?", being used by the facility for the skills fair, stated, "... Dry hands thoroughly with a single use towel; Use towel to turn off faucet; Your hands are now safe...".

Based on observations and interview it was determined that the facility failed to provide necessary maintenance services to maintain a sanitary and orderly interior. Findings include: Observations on 3/10/14 of tubs/showers in 28 resident rooms revealed caulking separation between the fiberglass and walls in 7 bathrooms or 25% of the sample. The resident rooms were 106, 201, 202, 203, 204, 207 and 208. An interview on 3/10/14 at 10:40 AM with E3 (maintenance) confirmed the separation in resident room 106. The separation had the potential to harbor mold. The facility recaulked the areas; they were found to have been corrected on 3/11/14. Findings were reviewed with E1 (Nursing Home Administrator) and E2 (Director of Nursing) on 3/12/14 at 1:15 PM.

Based on record review and staff interview it was determined that the facility failed to maintain clinical records for 3 (R2, R6 and SSR12) out of 13 sampled residents in accordance with accepted professional standards and practices that are complete, accurately documented and readily accessible. Findings include: 1a. R2 had a physician order, dated 4/6/12, which stated, "2 nurses must verify PD (peritoneal [MEDICAL TREATMENT]- blood filtering procedure through the abdomen necessary due to kidney failure) settings hs (at bedtime) continuous... 2 licensed nurses must verify PD settings are correct prior to starting. Must sign sheet." A clipboard with signatures verifying that 2 nurses checked PD settings was observed in R2's room throughout the survey. Review of the signature sheets revealed that from 1/20/13 through 4/8/13 there were 7 dates (1/24/13, 1/25/13, 2/4/13, 2/6/13, 3/7/13, 3/10/13, and 3/25/13) in which there was only one nurse signature instead of two as ordered. Findings were reviewed with E1 (Nursing Home Administrator) and E2 (Director of Nursing) on 4/11/13 during the exit conference. b. R2 had physician's orders [REDACTED]./12 for "Labs to be drawn at (hospital) the day of Nephrology (kidney specialist) appointments. Port needs accessed prior to transport." Documentation was reviewed for EMLA cream prior to port access and Nephrology appointments from 10/10/12 to 3/13/13. The facility failed to sign that EMLA cream was administered as ordered prior to 2 (10/18/12 and 3/13/13) out of 6 Nephrology appointments. Findings were reviewed with E1 (Nursing Home Administrator) and E2 (Director of Nursing) on 4/11/13 during the exit conference. 2. R6 was admitted to the facility in 2011 with multiple comorbidities including [MEDICAL CONDITION] with a [MEDICAL CONDITION] (breathing tube through the neck) and ventilator dependency (requires machine to breath for him). While reviewing R6's chart, an x-ray report, dated 12/19/12, was found which showed a left leg fracture. Upon further investigation, it was determined that the x-ray report belonged in R11's chart, not R6's. Findings were confirmed with E2 (Director of Nursing) on 4/9/13. 3. SSR12's record was reviewed to reconcile physician orders [REDACTED]. A hospital office visit, dated 2/18/13, listed an allergy to [MEDICATION NAME] (antibiotic) noted on 8/25/10 with a reaction of diarrhea. A physician order, dated 1/24/13, listed [MEDICATION NAME] for a urinary tract infection to be given twice daily for 10 days. Upon further investigation, it was determined that the physician order [REDACTED]. Findings were confirmed with E2 (Director of Nursing) on 4/9/13. E2 stated that having the wrong records in other residents' charts had the potential for error.

Based on record review and interview, it was determined that the facility failed to accurately identify pressure ulcers and consistently monitor these ulcers for one (R7) out of 12 sampled residents. Consequently R7 failed to receive the necessary treatment and services for the pressure sore. Findings include: The facility policy entitled, Assessment and Re-Assessment of a Resident with a Pressure Ulcer stated, "...I. Pressure ulcers should be assessed at least weekly...IV. Measure the wound in centimeters...VI. Determine the percent of the wound that has healthy granulation tissue. VII. Note the location of the wound. VIII. Note the color of the wound. IX. Describe the condition of the wound margins and the surrounding skin. X. Describe the exudates (drainage) color and odor. XI. Look for signs and symptoms such as redness, warmth, swelling, and pain. XII. Staging..." R7 was readmitted to the facility post hospitalization for correction of a left femur (thigh bone) fracture on 3/20/13. The Admission Assessment, dated 3/20/13, stated "...Eschar (dead tissue) present on heel of left foot measuring 2.25 cms (centimeters) x 2 cms. Small reddened area on sacral (tailbone) prominence." The facility failed to identify if the sacral redness was unblanchable (indicating a Stage 1 pressure ulcer) and failed to measure the size of the wound. Additionally, the facility failed to fully assess the left heel ulcer (e.g., description of surrounding skin, any drainage or redness) and failed to identify that it was an unstageable (unable to determine severity) pressure ulcer. On 4/5/13, the facility revised the care plan for skin integrity to reflect the presence of pressure ulcers on R7's left heel and sacrum. Interventions included: monitor healing of left heel and sacral area...dressing changes per MD (Medical Doctor) orders to left heel, [MEDICATION NAME] (protective dressing) to sacral area...Measure pressure ulcers weekly..." Review of the clinical record revealed that weekly measurements of the pressure ulcers were not completed until 3/31/13 (11 days later). On this date, the sacrum was measured as being 3 cm x 3 cm and identified as a Stage 1 pressure ulcer. The left heel ulcer was described as being necrotic and was identified as a Stage IV pressure ulcer, when in fact it remained unstageable. On 4/5/13, a nurse's note timed 3:49 PM stated the sacral pressure ulcer was a Stage 1, but no measurements were noted. This same note stated the left heel was a Stage III, when it remained unstageable. A nurse's note, dated 4/8/13 and timed 6:03 PM, stated the left heel wound was necrotic and measured 2 cm x 2.5 cm, and the sacral area was a superficial red wound and it was blanchable. Review of treatment administration records from 3/20/13 through 4/9/13 revealed that both treatments to the sacrum and left heel were completed as ordered. On 4/11/13 at 10:15 AM, R7's left heel and sacrum were observed during wound care. The left heel was observed to be an unstageable pressure ulcer measuring 2 cm x 2 cm. The sacrum was observed to be reddened and blanchable. During an interview with E1 (Administrator), E2 (Director of Nursing) and E3 (Assistant Director of Nursing) on 4/11/13 at 11:30 AM, findings of the facility failing to measure the wounds weekly, failing to thoroughly assess the wounds and failing to accurately identify the wounds were reviewed. E1 and E2 acknowledged the findings.

Based on observations, record review, staff interviews and review of other facility documentation, it was determined that the facility failed to ensure that the resident's environment remained as free of accident hazards as is possible. The facility failed to ensure that wheels on a crib were locked before transferring one (R8) out of ten (10) sampled residents from a wheelchair to the crib which resulted in a fall without injury. Additionally, the facility failed to ensure that medication carts were locked and that chemicals were secured in a locked room. Findings include: Review of the facility's policy, dated 03/09 and entitled, "Transferring the Resident" stated, "...To prevent accidents or injuries, the wheels of the bed, stretcher and/or wheelchair must always be locked when transferring a resident... Enlist the help of others to assist with the transfer..." 1. R8 was admitted to the facility on [DATE]. R8's [DIAGNOSES REDACTED]. The Annual MDS (Minimum Data Set) assessment, dated 9/25/11, revealed that R8 was coded as having one (1) fall without injury since the prior assessment. R8's care plan, dated 9/11/08 and entitled, "Safety - at risk for falls Diagnosis... Developmental delay..." listed interventions that included, "... Child assessed at risk for falls, Crib rails to be raised & (and) locked when child is in crib... Requires crib canopy... Lock wheels on any transport device when stationary,..." R8's care plan, dated 10/4/10 and entitled, "Mobility - d/t (due to) decreased mobility r/t (related to) weakness, dependent on staff for mobilization, learning to be more mobile... Diagnosis... Developmental delay..." listed interventions that included, "... Non-ambulatory - crawls around in bed and during floor play..." Review of R8's incident report of a witnessed fall, dated 9/11/11 and timed 8:30 PM stated, "This nurse (E9) called to room by CNA (name/E10), she explained that (name/R8) had fallen out of the bed and hit the floor, unsure of what hit the floor, pts (patient) arm/side or pts head. She explained that she and assisting CNA (name/E11) were trying to secure crib and pt pushed up and over the side. Full assessment done by this nurse, pt awake and alert, crying and pushing staff away, pt moving all extremities per baseline. Pt attempting to watch TV per baseline. VSS (Vital Signs Stable)." The on-call physician was notified and ordered to wake R8 every hour overnight to assess Neuro (neurological) status and call if baseline changed. E10's witness statement, dated 9/11/11 stated, "...While transferring... in the bed, ...immediately noticed... crib wasn't locked in place, causing it to move. After placing him in the crib safely, I pulled the crib back off the closet wall enough for (name/E11) to get to the other side and help me with ...care.... I tried to hurry and lock the wheel of the bed. I had one hand on (R8), but as the bed started moving I was trying to stop it and at that point took my hand off of (R8). I didn't realize that (E11) was on the back side of the crib trying to lock the back wheel to help me stabilize the crib as oppose (sic) to having a hold on (R8). This was my miss communication (sic). ... heard E11 scream...saw (R8) falling to the floor..." E11 stayed with R8 while E10 went to notify the nurse. E9 (nurse) and E12 (Charge nurse) came and assessed R8. E9 notified the physician on call. Review of E11's witness statement, dated 9/11/11 stated that as each CNA was checking/locking the wheels on the crib, "...we both took our eyes off of (R8). In that moment, he fell completely out..." During an interview on 12/19/11 at 2:00 PM, E7 (Compliance Manager) acknowledged the findings. She stated that it is expected that staff would ensure that wheel locks and crib side rail latches were secured. E7 stated that one person should have had their hand on R8. She denied any mechanical problems with equipment (ie. wheels or locks) but believed this accident occurred due to miscommunication between the CNAs. E7 stated that she spoke with both E10 and E11 and did an informal in service which included different scenarios, regarding what could have been done to prevent this accident and any reoccurrence. This was also reflected in the "Reviewer notes/Plan of Correction" portion of the incident report. The facility failed to follow the facility policy and R8's plan of care to safely transfer R8 from his wheelchair to his crib. 2. On 12/14/11 at 9:45 AM, the second floor medication cart was observed unattended and unlocked in the hall. E13 (nurse) acknowledged the cart should be locked. 3. During a medication pass observation on 12/15/11 at 10:00 AM, E14 (nurse) failed to lock the medication cart after she returned an eye ointment to the cart. E14 walked away from the med cart and headed toward another room down the hall. When asked by the surveyor if the cart should be locked, E14 acknowledged that it should and proceeded to do so. 4. On 12/16/11 at 8:20 AM, E3 (nurse) finished administering medications to a resident. E3 walked away from the med cart and headed toward another room down the hall. When asked by the surveyor if the cart should be locked, E3 acknowledged that it should and proceeded to do so. 5. On 12/19/11 at 12:00 PM, the first floor medication cart was observed unattended and unlocked in the hall. Several maintenance workers were observed nearby in the dining room. E3 came out of a resident room at the far end of the hall and headed toward the medication cart. She acknowledged the finding and stated that she forgot to lock it and was attending to alarms. 6. Observation on 12/13/11 during the initial tour with E2 (Director of Nursing) of the second floor revealed an unattended, unlocked medication cart with the medication keys left in the lock. E2 acknowledged the finding. 7. Observation on 12/16/11 at 8:45 AM revealed that the respiratory supply room #127 was unlocked and accessible to residents and contained the following: Bacitracin (5), 1 oz, "For external use only," Listermint (4), 3 oz, "Do not swallow, Keep out of reach of children," Sunscreen (4), 3 oz, "For external use only," Epi-Clenz (2) 16 oz, "For external use only," Hydrogen Peroxide (4) 4 oz, "For external use only," Syringes. An interview with E8 (Director of Facilities) confirmed that the door was unlocked. 8. Observation on 12/16/11 at 9:30 AM revealed that Respiratory Supply room #222 was unlocked and accessible to residents and contained the following: Listermint (5) 3 oz, "Do not swallow, Keep out of reach of children," Oral Balance (5), 1.5 oz, Keep out of reach of children, Hydrogen Peroxide (6), 4 oz, "For external use only," Hydrogen Peroxide (1), 16 oz, "For external use only," Curad Vitamin A & D ointment (4), 2 oz, "Keep out of reach of children," Sooth & Cool moisturizing, (7), 8 oz, For external use only, Epi-clenz (3) 16 oz, "For external use only," Syringes. Findings were reviewed with E1 (Administrator), E2 (DON) and E7 (Compliance Manager) during the exit conference. E2 stated that the children were never unsupervised.

Based on record review, staff interviews and review of facility documents, it was determined that the facility failed to ensure that an injury of unknown origin for one (1) resident (R1) out of 10 sampled was thoroughly investigated. Findings include: R1's Progress Notes included a nurse's note, dated 8/17/11 and timed 5:06 PM, that stated, "1530 (3:30 PM) - This nurse was notified by the nursing assistant that (name/R1) right upper thigh looked bigger than the left. Upon assessment, the right thigh is swollen and firm, warm to touch. Right thigh circumference measuring 20.5 inches. Left thigh measuring 19 3/8 inches... does not appear to be in pain. Smiles when spoken to Dr. (name) ordered for him to be sent to ...ER (emergency room ) for evaluation... " The facility's "Incident Report Form" and investigation, dated 8/17/11 was reviewed. E3's (nurse) witness statement, dated 8/17/11, stated "... right upper leg swollen, firm, warm to the touch. Right upper leg larger then (sic) the left." The incident report listed the only Witness(es)/Involved Persons as E3 despite the nurse's note that stated she was notified by a nursing assistant. During an interview on12/16/11 at 3:10 PM, E4 (CNA who accompanied R1 to the ER) stated that she had accompanied R1 to the ER but, had not been the CNA assigned to R1 on 8/17/11. The facility's records revealed that E5 (CNA) was assigned to R1 that day. During an interview on 12/19/11 at 11:45 AM, E5 stated that she was performing R1's morning care, when she noticed that his right leg appeared to be swollen and felt warm and noticed that one pant leg was tighter than the other side, which was loose. E5 stated she notified the nurse (E3). E3 and E6 (Director of Education) assessed R1. E5 stated that she was questioned by E6 and gave a verbal account to the nurses but denied completing any statements for the facility's investigation or being asked to write a statement regarding this incident by any staff. During an interview on 12/19/11 at 12:15 PM, E2 (Director of Nursing) stated that she had viewed the facility's surveillance/video tape with E7 (Compliance Manager), who interviewed the nurse(E3) and did the investigation. E2 recalled that a CNA noticed a small red/pinkish mark on R1's right groin, the doctor was notified and R1 was sent to the ER. E2 stated that R1 was being treated for [REDACTED]. On 12/19/11 at 12:30 PM, an interview was conducted with E7, E1 (Administrator) and E2. Initially, E7 incorrectly identified E4 as the CNA who reported R1's condition to E3 as she reviewed the incident report. E7 was informed by the surveyor that during interviews, it was discovered that E4 was the CNA who accompanied R1 to the ER and that E5 was the CNA who reported the incident. E2 reminded E7 that they had reviewed the video tape together. E7 was asked by the surveyor what she usually does as part of the investigation. E7 stated that she would gather documentation from the CNAs, nurses, anyone present, review the resident's history and view video tapes from the facility's surveillance cameras. E7 stated that she remembered viewing the video tape but failed to document that as part of the investigation. E7 acknowledged that statements/interviews were not obtained from all staff that had been involved in R1's care preceding the event. E1, E2, and E7 acknowledged that the facility failed to complete a thorough investigation.

Based on observation, staff interview, record review, review of facility policy and procedures and other documentation as indicated, it was determined that the facility failed to provide appropriate treatment and services to prevent complications related to gastrostomy tube feedings for one (R1) out of 4 sampled residents (including a subsampled resident). The facility failed to adequately assess for correct gastrostomy tube (GT) placement after replacing R1's GT on the evening of 2/20/11 and prior to administering 3 [MEDICATION NAME] tube feedings. The facility failed to ensure staff accurately assessed R1's abdomen and identified the significance of the changes in his condition. R1 developed a distended, tender abdomen, increased temperature, irritability and the facility nurse was unable to aspirate any tube feeding from the GT. R1 was sent to the ER. R1's temperature spiked to 105 degrees in the ER, his oxygen levels decreased and he went into full blown [MEDICAL CONDITION]. A surgeon emergently made an incision into R1's abdomen in the ER and placed a tube which drained approximately 300-400 cc's of tube feeding. R1 regained pulses after this, then emergency surgery was performed on 2/21/11, which included an exploratory laparotomy. The operative report stated as operative /invasive procedure findings as "perforated stomach with diffuse peritonitis". This same report stated as the postoperative diagnosis "Perforation of the stomach at the gatric peritoneal junction due to a fault passage from a gastrostomy tube". While it is unclear when the peritoneum (thin membrane that lines the abdominal wall and organs) was perforated, the facility failed to check placement of the GT they replaced on 2/20/11 by aspirating for [MEDICAL CONDITION] contents and listening for air in the abdomen prior to the administration of tube feedings. As a result, tube feedings entered R1's peritoneum, rather than his stomach, which resulted in harm to the resident. R1 was diagnosed with [REDACTED]. Findings include: Review of the "Mini ONE Balloon Button Caregiver's Reference Guide", for the GT device attached to R1 and used by the facility, stated, "... Replacing the Mini ONE Balloon Button... The stoma site may begin to close within the first hour after a device (GT) has been removed... 14. Ensure that the new tube is positioned properly by attaching a feed set and listening for air or aspirating stomach contents with the catheter tip syringe... Before feeding through the Mini ONE... important to verify proper placement inside the stomach as well as the functionality of the device. First, connect the extension set... used for feeding. Draw 10 ml (milliliters) of water into... syringe and attach it to the extension set. Pull back the plunger until stomach fluid (normally yellow or clear unless there is food in the stomach) is observed in the tube. Flush the stomach contents from the device with the water in the syringe. If stomach contents cannot be extracted from or injected into the stomach, reposition the patient and try again. Contact the physician if trouble persists." Review of the facility policy entitled "Confirming Feeding Tube Patency and Placement", dated 2/09, stated, "... 1. Verification of [MEDICAL CONDITION] tube patency and intactness should occur each shift. 2. Tube patency can be checked by flushing with a small amount of water. The tube should be easy to flush with little or no tension. 3. Verification of tube placement for a [DEVICE] may be completed by inserting air into the tube and listening over the stomach... 5. If patency is questioned and placement cannot be confirmed, discontinue use and notify the attending physician...". R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was dependent on staff for all care. A physician order, dated 2/17/11, stated, "[MEDICATION NAME] jr (nutritional formula) q4h (every 4 hours) continuous... 180 ml (milliliters) [MEDICATION NAME] over 1 hour via GT...". Review of facility documentation revealed that the tube feedings were due to be given at 1 AM, 5 AM, 9 AM, 1 PM, 5 PM and 9 PM. Review of nurse's notes, dated 2/20/11, revealed that R1 was picked up at 9:30 AM for a home visit. At 1:30 and 5:30 PM, E3 (LPN assigned to R1) called R1's Mom and it was reported that he was doing well. At 6:15 PM, R1's Mom called the facility and stated they effectively changed R1's [MEDICAL CONDITION] due to decreasing oxygen levels and a mucous plug and they were packing to return R1 to the facility. A nurse's note, dated 2/20/11 and timed 11:16 PM, stated that R1 returned to the facility at 7:30 PM accompanied by his parents and a family friend (nurse). Dad placed R1 in his crib; R1 was crying and agitated. E4 (RN assigned to R1) "... noticed... GTube was out and a small blood tinge (sic) drainage at the stoma (opening in abdomen)... while preparing to insert the old gtube, noticied (sic) the balloon leaking, inserted the old gtube without inflating the balloon with little resistant (sic) and small blood drainage, keep the stoma open. A new gtube botton (sic) was inserted by the charge nurse (E5) without any issues... Prn (as needed) tylenol given for crying and agitation at 2000 (8 PM)...". E4 checked R1's feeding pump and "... volume fed was 117ml... (physician orders were for 180 ml)". R1'[MEDICAL CONDITION] was changed again in the facility and he was "...calm and sleeping half an hour later...". A nurse's note, dated 2/21/11 and timed 4:51 AM, stated, "At 0230 (2:30 AM), patient febrile (had a fever), temp 101.3 axillary (in the armpit) and 103.2 rectal, heart rate in the 200's (elevated), O2 sats (oxygen saturation levels) above 97% (normal)... PRN [MEDICATION NAME] given. At 0330 (3:30 AM), temp 101.3 rectal and heart rate in the 180s... Charge nurse notified, will continue to monitor." Review of R1's heart rate from 2/19/11 at 2 AM to 2/20/11 at 2 AM ranged from 142-160. The record lacked evidence that the physician was notified at this time. A nurse's note, dated 2/21/11 and timed 6:32 AM, stated, "... [MEDICATION NAME] feed running a little late because pt received a feed at 1800 (6 PM) by patient's mom instead of 2100 (9 PM)...". Nurse's notes written by E6 (RN), dated 2/21/11 and timed 9:56 AM, stated, " Rec'd (received) pt this am with [MEDICAL CONDITION](elevated heart rate) to 210 bpm (beats per minute). T (temperature) 100.7 at (8 AM)... [MEDICATION NAME] given at (8:30 AM). Abd. (abdomen) distended/firm and tender to touch. fdg. (feeding) turned off. attempted to vent unable to get air or [MEDICAL CONDITION] content back. gt removed, lg amt of air expelled. replaced without difficulty, but still unable to vent... PCP (primary care physician) notified... recommended transferring to (hospital) for further eval... 911 activated and arrived at (10:10 AM). (Director of Nursing) accompanied pt." Review of ER physician notes, dated 2/21/11, stated, "... Informant: Mother, (facility) nurse... Mom notes that the [DEVICE] came out when he was visiting at home yesterday. they attempted to place it back with limited success. They were able to replace it at (the facility)... Abdominal... Girth 64 cm...". (last abdominal girth recorded 12/10/10 = 49cm.) Review of the hospital history and physical, dated 2/21/11, stated, "... presented to our Emergency Department this morning with worsening abdominal distention. Mom and dad are present... and provided the history... On the way returning him to (facility), they noted that his [DEVICE] became dislodged... nurse at the facility replaced it seemingly without incident... His last feed was at 5:00 a.m. He became progressively more distended although he did become febrile to as high as 100.7. He became more fussy and irritable over the morning... had a flat plate (x-ray) that showed free air under the diaphragm and multiple dilated loops. He started to have significant oxygen desaturations (low levels), spiked a temperature as high as 105, became profoundly mottled (discolored) and hypotensive (low blood pressure) at which time he went into an asystolic rhythm (no heart beat). He received chest compressions... (Name of physician) of General Surgery was called emergently to the emergency room . He was able to place an emergent peritoneal drain at which time milky white substance assumed to be his formula was found to come out in the drain... was stabilized and brought emergently to the Operating Room (OR) for an ex. lap (exploratory laparotomy). While in the OR, they noted profound peritonitis (inflammation of the peritoneum). He had an abdominal washout and his bowel loops were evaluated and cleansed. He had his [MEDICAL CONDITION] perforation repaired without incident... IMP (impression): ... now with acute on chronic [MEDICAL CONDITION] and severe systemic [MEDICAL CONDITION] response with significant peritonitis after Gtube replaced in false tract...". A surgical ER consultation report, dated 2/21/11, stated, "...When I arrived in the ED (emergency department)... in full blown [MEDICAL CONDITION] abdomen was extremely distended and tense... G tube was in place and there was formula evident in the extension tubing... (name of surgeon) removed the G tube and immediately placed a... drain... Copious amounts of formula spontaneously drained via the catheter (approx. 300-400 cc or 10-13 ounces)...". Review of a diagnostic inpatient consultation, dated 2/22/11, stated, "... [DEVICE] apparently fell out at home. It was not clear how long the tube was out at home prior to coming back to (facility)... surgery was called... drained "copious amounts of formula" and following this procedure pulses were regained...". A social service note, dated 2/22/11, stated, "... spoke with mother this morning... Gtube came out but that it did occur between the "car and his bedroom at (facility)... nurse at (facility) "shoved it back in and didn't check placement with the stethoscope...". The social worker also wrote that she received information from E2 (Director of Nursing at the long term care facility) which stated, "... believe that the gtube was out longer than what they (parents) were saying as the hole was already closed. The nurse did have a little resistance and that may be why the tube "went to the side...". A GI (gastrointestinal) consult, dated 2/23/11, stated, "... improving with significant peritonitis secondary to (due to) Gtube feeds in peritoneal space at outside facility... Postoperative Diagnosis: [REDACTED]. A neurology consult, dated 2/28/11, stated, "... perforated intestine... treated for [REDACTED]. A follow-up neurology consult, dated 3/4/11, stated, "... I believe... he is cortically blind and remains in a coma vigil state with periods of sleep and wake but with profound inability to interact with his surroundings...". On 3/7/11, R1's attending physician wrote, "... remains in the PICU (pediatric intensive care unit) on mechanical ventilation in a persistent vegetative state...". Review of R1's abdominal girths were as follows: 2/15/10- 46.5 cm (noted to have [MEDICATION NAME]) 3/6/10- 44 cm 3/8/10- 44 cm 12/10/10- 49 cm with note that there was no change from baseline. Review of the facility's incident report, dated 2/21/11 stated, "Received pt c (with) distended abd (girth 64- an increase of 15 cm from previous girth on 12/10) firm & tender to touch. Unable to aspirate [MEDICAL CONDITION] content. 2 ml H2O (water) flushed c no return... Tube removed, lg amts air escaped, then reinserted s (without) difficulty...". Written statements by E4 (RN) for 2/20/11, stated that when she reinserted the old GT, she "met resistance and small blood drainage, applied more lubricant, and gtube went in without any issues". She stated R1 was asleep at 9:30 PM, she started R1's scheduled 9 PM [MEDICATION NAME] feed around 11:30 PM, and his 1 AM and 5 AM [MEDICATION NAME] feeds about 1 1/2 hours later than scheduled. E4 stated that R1 only woke up crying during care. E4 denied forcing the old GT in during a telephone interview with E2 (Director of Nursing) on 2/24/11. When asked by E2 "... before you started the first feed through the new GT, did you check placement by inserting air or aspirating [MEDICAL CONDITION] contents?" E4 replied, "No because inserting air is really for a NGT ([MEDICAL CONDITION] tube), I would have heard air no matter where the GT went...". E4 denied problems flushing the GT or infusing the tube feeding. Written statements for 2/12/11 by E6 (RN assigned to resident), stated that after assessing R1, she attempted to vent his GT, but was unable to get air or formula. She removed the GT, a large amount of air was expelled, then E6 replaced the GT without difficulty, but continued to be unable to vent for air or [MEDICAL CONDITION] contents. R1 was subsequently sent to the ER. The facility provided a timeline of events after reviewing audio and visual footage, dated 2/21/11. The timeline revealed that E4 reinserted R1's old GT (to keep stoma patent) 11 minutes after his return to his crib from a home visit and it took approximately 30 seconds. 10 minutes after the old GT was placed, E5 placed a new GT. This surveyor viewed the audio and visual footage from the time R1 arrived back in his room until E5 inserted a new GT. The audio and visual quality was poor, however, it did not appear to be an emergent situation. The facility also provided a summary of documentation with the DLTCRP (Division of Long Term Care Residents Protection) investigator, dated 3/4/11, which stated, "... DON (Director of Nursing- E2) tells investigator while demonstrating with a button that you can ausculator (sic) air or aspirate stomach contents but that neither are a definitive indicator for proper placement. The only indication is an xray. DON explained that the GTube had been in place for 15 months and a good tract was established (replacements have occurred every 3 months and as needed with no incident for this child)... The investigator asked if the nurse placing the new tube took responsibility for checking placement of the GTube. Again the DON explained that it is not our practice that if there is no resistance placement is accepted...". E7, the facility (staff development) nurse was interviewed on 3/10/11. When asked how patency was checked on a GT, she stated they were flushed with water and would not flush if the tube was blocked. E7 stated the facility does not auscultate for air, as it would be heard whether in the stomach or not and she stated they do not aspirate as it can damage the anti-reflux valve in the Mini One button (attached to GT) and there may not be any [MEDICAL CONDITION] contents anyway. After reviewing the manufacturer's instructions for the Mini One button with E7, including listening for air or aspirating stomach contents after replacing a GT and to aspirate for stomach contents prior to feeding through the GT, E7 stated that the instructions were probably for adults, not children. A brochure for patients and caregivers for the Mini One Balloon Buttons that came with the kit used by the facility had a baby on the front cover. After the incident with R1, the facility revised their policy entitled "Confirming Feeding Tube Patency and Placement", dated 2/11. In addition to information listed on the old policy, they added "*** Please note that if there is NOT a witness when a GT comes out OR of (sic) you have any difficulty re-inserting the GT, contact the physician prior to infusing feeds or giving any medications. An x-ray may be needed to clarify proper placement" was added. While it was unclear if the GT came out at home and how long the GT was out, the facility was told that the tube had just come out and they reinserted a new one. The facility, however, failed to ensure proper placement of the GT by aspirating for [MEDICAL CONDITION] contents prior to initiating GT feedings as per the manufacturer's instructions. The facility administered approximately 540 cc of tube feeding via GT to R1, he developed significant abdominal distention, fever and tenderness which resulted in leakage of his feeding into the peritoneum (instead of the stomach) and severe peritonitis. R1 required emergent drainage of his peritoneum in the ER which drained 300-400 cc's of tube feeding, and emergent abdominal surgery. Additionally R1 sustained [MEDICAL CONDITION], developed septic shock, and sustained significant brain damage.

Based on observation, staff interview, record review, review of facility policy and procedures and other documentation as indicated, it was determined that the facility failed to notify the physician for one (R1) out of 4 sampled residents (including a subsampled resident) who experienced a change in condition. On 2/21/11 at 4:51 when R1's temperature was 103.2 rectally accompanied by a heart rate in the 200s the facility failed to notify the physician. Findings include: R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was dependent on staff for all care. Review of nurse's notes, dated 2/20/11, revealed that R1 was picked up at 9:30 AM for a home visit. At 1:30 and 5:30 PM, E3 (LPN assigned to R1) called R1's Mom and it was reported that he was doing well. At 6:15 PM, R1's Mom called the facility and stated they effectively changed R1's [MEDICAL CONDITION] due to decreasing oxygen levels and a mucous plug and they were packing to return R1 to the facility. A nurse's note, dated 2/20/11 and timed 11:16 PM, stated that R1 returned to the facility at 7:30 PM accompanied by his parents and a family friend (nurse). Dad placed R1 in his crib; R1 was crying and agitated. E4 (RN assigned to R1) "... noticed... GTube was out and a small blood tinge (sic) drainage at the stoma (opening in abdomen)... while preparing to insert the old gtube, noticied (sic) the balloon leaking, inserted the old gtube without inflating the balloon with little resistant (sic) and small blood drainage, keep the stoma open. A new gtube botton (sic) was inserted by the charge nurse (E5) without any issues... Prn (as needed) tylenol given for crying and agitation at 2000 (8 PM)...". E4 checked R1's feeding pump and "... volume fed was 117ml... (physician orders [REDACTED]. R1'[MEDICAL CONDITION] was changed again in the facility and he was "...calm and sleeping half an hour later...". A nurse's note, dated 2/21/11 and timed 4:51 AM, stated, "At 0230 (2:30 AM), patient febrile (had a fever), temp 101.3 axillary (in the armpit) and 103.2 rectal, heart rate in the 200's (elevated), O2 sats (oxygen saturation levels) above 97% (normal)... PRN [MEDICATION NAME] given. At 0330 (3:30 AM), temp 101.3 rectal and heart rate in the 180s... Charge nurse notified, will continue to monitor." Review of R1's heart rate from 2/19/11 at 2 AM to 2/20/11 at 2 AM ranged from 142-160. The record lacked evidence that the physician was notified when R1's condition changed and there was an elevated temperature, accompanied by a heart rate in the 200s.